Shrewsbury and Telford Hospital NHS Trust

5. Mr I, represented by his mother (Ms I), complains about the care and service he received at the Trust between 17 August 2022 and October 2024.

6. Specifically, he complains the Trust inappropriately discharged him after his alcohol and drug overdose on 17 August 2022.

7. Mr I says because of the inappropriate discharge he suffered a seizure two days after his discharge and was readmitted for detox and management of his withdrawal which required a two-week inpatient stay.

8. Mr I is seeking an apology, service improvements and financial remedy.

9. Mr I attended the Trust’s emergency department (ED) on 17 August 2022 following a drug and alcohol overdose. He was discharged on the same day.

10. Two days later Mr I suffered a seizure and was readmitted to the Trust as an inpatient for two weeks because of alcohol withdrawal.

15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

16. Mr I complains the Trust did not adequately assess his condition when he attended the Trust’s ED. He says because of this he was discharged prematurely and suffered an at home seizure.

17. In its response the Trust said Mr I was provided with appropriate care during his ED visit on 17 August. It explained Mr I was triaged before blood tests, clinical observations and an ECG were performed. An ECG (electrocardiogram) is a test that records the electrical signals travelling through your heart. The Trust said there was no indication at the time of assessment that Mr I was in severe alcohol withdrawal.

18. The Trust also said Mr I was referred to its Mental Health Liaison Team (MHLT) which also referred him to a Crisis Resolution Home Treatment Team (CHTT)

19. NICE CG115 sets out the approach clinicians should take when managing alcohol use disorders. It states that patients with alcohol withdrawal symptoms, such as seizures, delirium tremens, or confusion, should be admitted for inpatient care.

20. This is balanced by NICE NG225 which highlights the importance of patients who have overdosed through a psychosocial assessment. This includes identifying risks (such as alcohol dependency or ongoing mental health concerns) and creating a plan for follow-up care.

21. When Mr I attended the Trust, records show he was triaged at 9.10pm through clinical observations and he was recorded as coherent and showing normal vital signs. Once the blood tests and ECG were completed, the results were reviewed and showed no concerns.

22. Mr I was then reviewed by the Trust’s MHLT team who documented Mr I’s alcohol dependency and noted the overdose as an act of self-harm. The Trust then referred Mr I to the CHTT with an appointment arranged for the following day.

23. Our adviser explained there is no indication within the records that Mr I was showing signs of acute withdrawal on 17 August. Our adviser explained signs of acute withdrawal include seizures, confusion and abnormal vital signs.

24. We are satisfied with the Trust actions to refer Mr I to the appropriate mental health team once it had confirmed Mr I was in a stable condition following his overdose. We consider the Trust acted in line with the expected professional standard when it assessed Mr I during his ED admission on 17 August.

25. While we have seen no indication anything went wrong in how the Trust managed Mr I’s discharge, we recognise the seizure he experienced, and the subsequent readmission was a distressing and traumatic event for him and his family.

26. We would like to thank Mr I and his family for bringing this complaint to us and sharing this personal information of a vulnerable time in Mr I’s life. We are sorry we could not provide a more agreeable outcome.

1. We have carefully considered Mr I’s complaint about Shrewsbury and Telford Hospital NHS Trust (the Trust).

2. We were sorry to hear about Mr I’s experience following his discharge in August 2022 and the impact this had on his health and emotional well-being. We recognise the wider impact this had on Mr I’s family and the distress they experienced seeing him in pain.

3. We recognise the content of our report may be triggering and upsetting to read. We understand if Mr I and his family need time to read and process our view.

4. We have considered Mr I’s complaint that the Trust inadequately managed his discharge, and we have seen no indication anything went seriously wrong.